Bimalleolar fractures

1. • Acute Ankle Fracture Dislocation
• Fracture Closed Complete Transverse
Displaced Medial and Lateral Malleolus Left
secondary to Motor Vehicular Accident
• Weber B
• Lauge-Hansen SER Stage IV
• Dias-Tachdjian Stage SI
• AO 44A2.3

7. TALOCRURAL ANGLE
Assess for fibular shortening
Measurement
Mortise view
Line along the distal tibial plafond
articular surface
Line joining the tips of both malleoli
Interpretation
Normal: 83° ± 4° 2 or 8-15° 3
Fibular shortening: >2° difference to the
contralateral side

8. TALAR TILT
MORTISE VIEW
Measurement of the angle between the talus and
the distal tibia, used in the assessment of:
1. Ankle instability
2. Ankle osteoarthritis
Measurement
Talar tilt is measured on either AP or mortise view
radiographs of the ankle.
Talar tilt is the angle between the articular surface
of the talar dome and the articular surface of the
tibial plafond.
Interpretation
Normal values
<2° on non-stress radiographs
<5° on inversion stress radiographs
Talar tilt ≥2° upgrades Kellgren and Lawrence ankle
OA from grade 3a to 3b, which is associated with
worse clinical outcomes

9. MORTISE VIEW
Mortise joint space should
uniformly: < 4mm
Lateral Clear Space: <3-6mm
Distal tibiofibular overlap >1mm
Fibular fossa: Visible
AP VIEW
Distal tibio-fibular joint: < 5.5mm
Distal tibofibular overlap: >6mm
Equal Horizontal and Medial CS:
3mm

10. MORTISE VIEW
Mortise joint space should
uniformly: < 4mm
Lateral Clear Space: <3-6mm
Distal tibiofibular overlap >1mm
Fibular fossa: Visible
AP VIEW
Distal tibio-fibular joint: < 5.5mm
Distal tibofibular overlap: >6mm
Equal Horizontal and Medial CS:
3mm

11. S

14. PLAN
PLAN: Debridement ankle left,
Closed vs Open reduction
multiple pinning lateral and
medial malleolus left
Lined up as STAT CASE
LABORATORIES:
HEM: 12.8
WBC: 22.2
PLAT: 310
ESR: 120
CRP:140
Covid 19 PT-PCR negative
(+)Covid positive exposure 11-10-22

15. PHYSIS
Distal tibial physis
• Contributes 45% of the growth
of the tibia
• Ossifies between 6 and 12
months of Age
• medial malleolus appears at 7
years in girls and 8 years in
boys.
• The medial malleolus usually
ossifies as a down ward
extension of the distal tibial
ossific nucleus
• The distal aspect of the tibia is
completely ossified by 14 to
15 years of age and fuses with
the diaphysis at 18 years
Distal fibula
• Ossifies during the second year of
life, generally between the ages of
18 and 20 months.
• This physis usually closes 12 to 24
months later than the distal tibial
physis
CHAPTER 30 Lower Extremity Injuries, pg1379
Tachdjian’s Pediatric Orthopaedics 6th ED

16. ANATOMY
Ankle Syndesmosis
• Interosseous Ligament
• Anterior and Posterior Inferior Tibiofibular Ligaments
• Inferior Transverse Ligament Posteriorly

17. Medial Ligamentous Structure
Deltoid ligament
Superficial
• Anterior Talotibial
Ligament
• Posterior Talotibial
Ligament
• Tibionavicular
Ligament
• Calcaneotibial
Ligament
Deep
• Primary restraint to
lateral
displacement of
talus

18. LATERAL LIGAMENTOUS STRUCTURE
• Anterior
Talofibular
Ligament (ATFL)
• Calcaneofibular
Ligament (CFL)
• Posterior
Talofibular
Ligament (PTFL)

19. Type I and II:
• Often amenable to closed tx
• Lower risk of physeal arrest
Type III and IV:
• More likely to require operative tx
• Higher risk of physeal arrest
Classification (Anatomic)
Salter-Harris Classification
High interobserver correlation
Correlated with outcomes

20. CLASSIFICATION (MECHANISTIC)
DIAS-TACHDJIAN (1978)
4 Types
A. Supination-inversion
B. Pronation-eversion
external rotation
(PEER)
C. Supination-external
rotation
D. Supination-
plantarflexion

21. SUPINATION INVERSION
Grade 1: Adduction or inversion force
avulses fibula
• SH type I or II, rarely can be an epiphyseal
fracture
Grade 2: Further inversion tibia fracture
• Compressive force to medial malleolus
• SH type III or IV

22. VARIANTS OF GRADE II SUPINATION–
INVERSION INJURIES
A: SH type I fracture of the distal tibia and fibula.
B: SH type I fracture of the fibula, type II tibial fracture.
C: SH type I fibular fracture, type III tibial fracture
D: SH type I fibular fracture, type IV tibial fracture

23. SUPINATION INVERSION
• McFarland Fracture
• Higher likelihood of nonunion
Intra-articular fracture
• Delayed union not uncommon
• Late displacement can occur
• Growth arrest most common in this pattern Up
to 40-50%
• Adequacy of reduction is only predictive factor
of physeal arrest

24. PRONATION-EVERSION, EXTERNAL-
ROTATION
• This injury results when an
eversion and lateral
rotation force is applied to
a fully pronated foot
• Tibial SH I/II fracture
pattern
• Thurston-Holland fragment
posterolateral
• Transverse fibula fracture
• Can be a greenstick fracture
• Premature physeal closure
is common

25. Supination-External Rotation
Grade 1:
• External rotational force
• SH type II tibia fracture
• Thurston Holland fragment visible on
AP Xray
• Differentiates from Supination-
plantarflexion
• Tibial epiphysis displaces
posterolaterally
• Similar to Supination-plantarflexion
Grade 2:
• Spiral fx distal fibula metaphysis
• Anteroinferior to posterosuperior
• Complications:
• External rotation deformity can
occur due to incomplete reduction

26. WEBER CLASSIFICATION

27. COTTON FRACTURE
Cotton fracture is a three-part fracture of the ankle involving the lateral
malleolus, medial malleolus and distal posterior aspect of the tibial plafond
(posterior malleolus)

28. TREATMENT
A. Location of fracture
B. Amount of displacement
C. Age of child (how much growth remains)
D. Distal tibia physis contributes:
• 3-4 mm growth per year
• 35-45% of overall tibia length
• Follow up X-rays for 6-12 months to evaluate for
physeal closure

29. NON-OPERATIVE
• SLCC for 4 weeks
• Weight bearing is restricted for initial
2 weeks
• Additional immobilization is based on
amount of healing present

30. OPERATIVE INDICATIONS
• Open fractures or
injuries with severe soft
tissue injury
• Displacement of the
articular surface
(>2mm)
• Unable to obtain or
maintain acceptable
reduction

31. TREATMENT